Despite the coronavirus pandemic and compromised tourist season, the Institute Naval Medicine of the Support Command, based in Split, has received an unexpected number of patients for the hyperbaric chamber treatment. The Croatian Armed Forces’ medical staff has successfully treated the victims in such circumstances as well

The COVID-19 pandemic has stretched the national health system, and the epidemiologic measures created an impression in the public that the rest of the system is operating to a limited extent or less intensively.  On the other hand, a smaller (but not much) number of tourists this year on the Adriatic coast and islands should mean less work for our doctors. It couldn’t be further from the truth for the emergency response teams of the Institute of Naval Medicine in Split – a unit of the Military Medical Centre of the Support Command.  The Institute for Naval Medicine Institute comprises the Department of Naval and Hyperbaric Medicine, tasked with support to diving activities in the Croatian Armed Forces. Their most responsible duty consists in hyperbaric treatments of victims of diving incidents. Most hyperbaric interventions are conducted for civilian divers during the tourist season, pursuant to the contracts with civilian health institutions.  An unusually high incidence was registered over the past weeks, and some the tourist season on civilian divers, literally a matter of life or death, explains for the Lieutenant Colonel Pavle Jovović, a medical doctor and deputy head of the Department.

Epidemiological measures

 “We were surprised by the high incidence of interventions too.  There had rarely been this many patients, even during the successful seasons. This year we had 15 emergency interventions just by 24 August, which suggest that that diving tourism has not been affected by the crisis that much; estimates indicate 1-2 cases of decompression occur in 10,000 recreational divers”, says Dr.  Jovović. The epidemic did affect the work organisation and at the moment the Department only treats emergency cases.

The responsible European authorities issued recommendations on the procedure for reception and treatment of patients in the bar chamber amid the new epidemiologic measures, so on arriving to the hospital the patients first take a COVID-19 test.

The hyperbaric chamber of the Split Institute of Naval Medicine is responsible for the diving incidents in central and south Adriatic, whereas the bar chambers installed Centre in Rijeka and in Pula and Crikvenica cover the area of Istria and north Adriatic.

 “The peak period was from 14 to 15 August; we even received two requests for intervention in one single day, which is rare. They took place in the aquatory of Vis and Dubrovnik respectively”. Dr. Jovović told us about the particularly difficult case of a Polish diver who dived near Dubrovnik with a group of a diving centre.

“The diving took some 40 minutes, at a maximum depth of 40 m. The diving had probably been planned poorly and the diver consumed up the air supply too quickly, he emerged too fast and was caught in panic, which caused decompression sickness. He also fainted and floated on the surface.  He was brought to the intensive care unit of the Dubrovnik Hospital as a potential victim of a drowning, in a life-threatening condition, non-communicative, intubated and was connected to a ventilator. He endured the night and was disconnected from the ventilator but all four extremities were numb. He then responded to the verbal stimuli and we learned about the circumstances of the accident, while the neurological complications were associated with decompression sickness. After consultation with our Institute, the patient was transported to the Neurology Department of the University Hospital Centre in Split, and to our Institute for recompression treatment, which is the only solution in such cases. “Upon arrival the patient displayed slow and difficult contact, frequent painful hand cramps and difficulty breathing, but he was then taken care by the very experienced medical team, comprised of Dr. Jovović, senior nurse 1^st Lieutenant Diana Ujević and hyperbaric chamber operator Sergeant Major Marko Kokeza.

The first recompression therapy was especially demanding, every breath was a struggle.  The patient the five-hour treatment at the pressure of 2.8 bar, but had difficulties with the hyperbaric chamber mask so the team had to make pauses more frequently than previewed by the treatment protocol. “The diver did endure the first three days of rigorous recompression treatment required by his condition and is now following a standard therapy comprising 1-2 month treatment in hyperbaric chamber and physical therapy, aimed at improving his quality of life”, concludes Dr. Jovović.

The recovered Polish diver will continue treatment at home, and the Department will contact the respective staff about his condition. In the grave cases which receive treatment following the recompression in Split the Institute keeps updated with the patients for the purpose of managing the treatment with future patients, the possible health consequences and the circumstances within the patient treatment crucial for the outcome.  

”It is highly important for the training of future divers and students, where our Institute is engaged too. Most patients willingly inform us of the treatment outcome”, says Dr. Jovović.

Dr Jovović is proud of his team, and shares conviction that technology is important but not crucial.   “Each patient is specific in his own way. Expertise is crucial and experience is invaluable. Knowledge evolves and you have to keep pace with new recommendations with respect to pre-hospital procedures and in decompression treatment.

You don’t want to harm your patient even with the best of intentions for the lack of knowledge. Most of our members have worked together for a long time and have a lot of experience.  It is not all about technology, although it is important. What you really need is a metal barrel with compressed air and the possibility for the patients to breathe oxygen within a closed circuit. The rest is just manometers, monitoring units, valves, pipes and gas analysers assembled in a nice compound and smaller than they used to be 40 or 50 years ago”, says Dr. Jovović .

The Department proved the competence of fulfilling the tasks, including the most responsible ones, in most unpredictable conditions. It is how it should be in the future and with the new staff members too.  

 “A new doctor has joined our staff, and is now taking the training in hyperbaric medicine, including a diving course. It is a biggest motivation for our staff to know that we have helped someone and that patients feel at ease with the communicative and nice medical staff, who always find the time to talk to them and offer advice.

I can confirm the news that our Institute has received positive evaluations from the insurance companies from Switzerland and Germany, based on the ratings of our patients. We do not just do our job, we care about our patients and they realise that.  To ensure continuity it takes investing into the personnel and prioritising contacts with our colleagues from partner countries, to enable the exchange of experiences and joint projects, “concludes Dr. Jovović.